Treatment of short bowel syndrome patients with colon-in-continuity

ABSTRACT

Intestinal absorption is enhanced in short bowel syndrome patients presenting with colon-in-continuity by treatment with a GLP-2 receptor agonist, such as teduglutide.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.16/257,346, filed Jan. 25, 2019, which is a continuation of U.S. patentapplication Ser. No. 15/286,411, filed Oct. 5, 2016, which is acontinuation of U.S. patent application Ser. No. 14/745,157, filed onJun. 19, 2015, now U.S. Pat. No. 9,545,434, issued Jan. 17, 2017, whichis a divisional of U.S. patent application Ser. No. 12/938,117, filed onNov. 2, 2010, now U.S. Pat. No. 9,060,992, which is a divisionalapplication of U.S. patent application Ser. No. 11/262,980, filed onNov. 1, 2015, now U.S. Pat. No. 7,847,061, which claims benefit of U.S.Provisional Application Ser. No. 60/623,233, filed on Nov. 1, 2004, eachof which is incorporated herein by reference in its entirety.

FIELD OF THE INVENTION

This invention relates to products and methods useful medically to treatpatients presenting with short bowel syndrome. More particularly, theinvention relates to glucagon-like peptide 2 (GLP-2) and other GLP-2receptor agonists effective to improve intestinal function particularlyin patients presenting with short bowel syndrome withcolon-in-continuity.

BACKGROUND TO THE INVENTION

The estimated prevalence of short bowel syndrome (SBS) patients withnon-malignant disease requiring home parenteral nutrition (HPN) is atleast 40 per million of the U.S. population. SBS usually results fromsurgical resection of some or most of the small intestine for conditionssuch as Crohn's disease, mesenteric infarction, volvulus, trauma,congenital anomalies, and multiple strictures due to adhesions orradiation. Surgical resection may also include resection of all or partof the colon. SBS patients suffer from malabsorption that may lead tomalnutrition, dehydration and weight loss. Some patients can maintaintheir protein and energy balance through hyperphagia; more rarely theycan sustain fluid and electrolyte requirements to become independentfrom parenteral fluid.

Although long-term parenteral nutrition (PN) is life saving in patientswith intestinal failure, it is expensive, impairs quality of life and isassociated with serious complications such as catheter sepsis, venousocclusions and liver failure. Treatments that amplify absoluteintestinal absorption, and eliminate or minimize the need for PN havegreat potential significance to SBS patients.

The endogenous meal-stimulated hormone, glucagon-like peptide-2 (GLP-2),raises considerable interest for SBS patients. GLP-2 functions to slowgastric emptying, reduce gastric secretions, increase intestinalblood-flow and stimulate growth of the small and large intestine. Inanimal studies, GLP-2 administration induces mucosal epithelialproliferation in the stomach and small and large intestine bystimulation of crypt cell proliferation and inhibition of enterocyteapoptosis.

SBS patients with end-jejunostomy and no colon have low basal GLP-2levels and limited meal-stimulated GLP-2 secretion due to removal ofGLP-2 secreting L-cells, which are located primarily in the terminalileum and colon. This GLP-2 deficiency results in a minimal adaptiveresponse following resection and could explain the gastrichypersecretion, rapid intestinal transit and lack of intestinaladaptation observed in these SBS patients.

Jeppesen et al. (Gastroenterology 2001; 120:806-815) have describedpositive benefit in an open-label study using pharmacologic doses ofnative GLP-2 in SBS jejunostomy patients. There was significantimprovement in intestinal wet weight absorption and a more modestimprovement in energy absorption that led to an increase in body weight,lean body mass and a rise in urinary creatinine excretion.

In contrast, SBS patients with colon-in-continuity have elevated basalendogenous GLP-2 levels resulting in an adaptive response to resectioncharacterized by improved wet weight gain and energy absorption. Thepotential for added benefit of pharmacologic doses of GLP-2 receptoragonists in these patients is not obvious and has not been studied.

SUMMARY OF THE INVENTION

It has now been determined that intestinal absorption is enhanced in SBSpatients presenting with colon-in-continuity when those patients aretreated with a GLP-2 receptor agonist.

Thus, in one aspect, the present invention provides a method forenhancing intestinal absorption in a patient with short bowel syndrome,comprising the steps of selecting for treatment a short, bowel syndromepatient presenting with at least about 25% colon-in-continuity withremnant small intestine, and treating said patient with a GLP-2 receptoragonist to enhance intestinal absorption by said patient.

In a related aspect, the present invention provides for the use of aGLP-2 receptor agonist in the preparation of a medicament for enhancingintestinal absorption in short bowel syndrome patients presenting withat least about 25% colon-in-continuity with remnant small intestine.

In a preferred embodiment, the GLP-2 receptor agonist is [Gly2]hGLP-2,known as teduglutide.

BRIEF REFERENCE TO THE DRAWINGS

Embodiments of the invention are now described with reference to theaccompanying drawings in which:

FIG. 1 illustrates results measured in terms of fecal wet weight,intestinal wet weight absorption and urine weight in the individualpatients at Baseline (Days −3 to 0), during treatment (Days 18 to 21),and at follow-up (Days 39 to 42).

FIG. 2 illustrates results measured in terms of fecal energy excretionand intestinal absorption in the individual patients at Baseline (Days−3 to 0), during treatment (Days 18 to 21), and at follow-up (Days 39 to42).

DETAILED DESCRIPTION

The positive effect of GLP-2 receptor agonists on intestinal absorptionin SBS patients that retain at least some, e.g. >25%, of their colon isparticularly surprising.

These patients have essentially retained GLP-2 producing tissue and,indeed, show elevated basal levels of the endogenous GLP-2 that can beas high as meal stimulated levels in normal, healthy individuals andthat, in normal individual, is responsible for maintenance of theintestinal lining required for intestinal absorption. There isnevertheless significant clinical benefit for these patients, manifestprincipally as enhanced intestinal absorption as indicated by increasedabsolute wet weight absorption, when they are treated in accordance withthe present method.

More particularly, patient candidates for the present treatment arethose presenting with SBS resulting from small intestine resection whichmay be secondary to Crohn's disease, vascular ischemic disease,malrotation or volvulus, trauma, congenital anomalies, or multiplestrictures due to adhesions or radiation and who require parenteralnutrition to meet their needs. As patients presenting with short bowelsyndrome, such patients typically retain, following resection, a lengthof small intestine that is within the range from at least about 25 cmand at most about 200 cm., e.g., from about 50-150 cm. Such SBS patientsinclude those patients presenting with jejunostomy, in which part of thejejunum is resected and generally all of the ileum, and/or ileostomy inwhich part of the ileum is resected and the jejunum may or may not bepresent. SBS patients with jejunostomy or ileostomy generally do nothave any remaining colon, but if they do, it is not in continuity withthe remnant small intestine.

SBS patients selected for treatment by the present method are those whoretain, in continuity with remnant small intestine, at least some lengthof their colon, such as at least about 25%, and desirably 30%, 35%, 40%,45% and preferably at least 50%, 60%, 70%, 80%, 90% or more. Theremaining length of colon typically will be determined from the surgicalrecords of a patient candidate. Expressed in other terms, preferredcandidates for the present treatment are short bowel syndrome patientswho retain colon sufficient to produce endogenous GLP-2 at levels thatare at least greater than the negligible levels produced by patientswith no colon, and ideally are similar to those GLP-2 levels produced byhealthy volunteers. Endogenous GLP-2 levels for normal, healthyindividuals are 15±2 pmol/L fasted, and 61±9 pmol/L fed. Candidates forthe present treatment thus are SBS patients that retain sufficientfunctional colon to produce at least about 10%, 20%, 30%, 40%, 50% ormore of such levels in the fed state, e.g., at least about 5 pmol/L fed,and desirably 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65 and 70pmol/L endogenous GLP-2 in the fed state.

In a preferred embodiment, treatment candidates are those short bowelsyndrome patients who retain at least 50% or more of colon length incontinuity with remnant small intestine. Such a treatment candidate isidentified herein as a patient with >50% colon-in-continuity. In otherpreferred embodiments, the SBS patient with colon-in-continuity has aremnant small intestine at least about 50 cm in length which, desirablybut not essentially, incorporates at least a portion of the ileum.

The patients can be selected for treatment by the present method at anytime following the surgical resection. That is, patients that areundergoing adaptation, as well as those who have had sufficient time toadapt following the surgery, are acceptable treatment candidates.

Treatment of short bowel syndrome patients presenting withcolon-in-continuity, in accordance with the present method, is effectiveto enhance intestinal absorption, particularly of fluid including waterand salts, but including nutrients as well. This effect is revealedparticularly as a treatment-mediated, statistically significant increasein absolute wet weight absorption, which is determined by subtractingfecal wet weight from diet wet weight using a vigorous nutrientabsorption test. The effect of treatment is also generally seen as areduction in fecal wet weight, an increase in urine wet weight, areduction in energy excretion (measured as herein described), and inother respects noted in the examples herein.

The present treatment method entails dosing the selected patient with aGLP-2 receptor agonist using a treatment regimen effective to enhanceintestinal absorption. Such GLP-2 receptor agonists are characterized asmolecules that bind with, preferably selectively, and stimulate thehuman GLP-2 receptor, as reported by Monroe et al. in U.S. Pat. No.6,077,949 issued Jun. 20, 2000, incorporated herein by reference.Briefly, GLP-2 receptor agonists are revealed as agents that triggerproduction of, or trigger an elevation in the level of, a secondmessenger coupled to the human GLP-2 receptor, when exposed to a hostcell that produces that receptor naturally or is transfected with DNAencoding that receptor.

In one embodiment of the invention, the GLP-2 receptor agonist is humanGLP-2. In other embodiments, the GLP-2 receptor agonist is a vertebrate,e.g., mammalian, homolog of human GLP-2. Thus, GLP-2 receptor agonistsuseful in embodiments of the present invention include GLP-2 having thesequence found in GLP-2 endogenous to human, cow, pig, primate, sheep,rodents including mouse, rat, degu and the like, and other vertebratespecies.

In other embodiments, the GLP-2 receptor agonist is an analog of humanGLP-2, which incorporates at least one, and usually not more than 5,e.g., 1, 2 or 3, amino acid substitutions or additions, and may alsohave a C-terminal truncation of from 1 to 5 or more amino acids.

In a preferred embodiment, the GLP-2 receptor agonist is a GLP-2 peptideanalog that is altered to prolong serum half-life. In a particularlypreferred embodiment, the GLP-2 peptide incorporates an amino acidsubstitution that renders the peptide resistant to the endogenous enzymedipeptidyl peptidase IV (DPP-IV). Such analogs incorporate anappropriate substitution of the Ala2 residue desirably, but notessentially, by a genetically encoded amino acid, to permit recombinantproduction of the desired protein. Amino acids that can usefullysubstitute at Ala2 to provide GLP-2 analogs that retain GLP-2 receptoragonist activity and are less susceptible to DPP-IV include GLy, D-Ala,Val, Glu, Lys, Arg, Leu and Ile. Still other GLP-2 analogs include thosesubstituted at Met10 by an amino acid that is less sensitive tooxidation.

In alternative embodiments, the GLP-2 peptide, or GLP-2 peptide analogis derivatized, for instance at an internal or substituted lysine, toprolong serum half-life by conjugation with lipophilic groups, withpolyethylene glycol groups, with albumin or with any other functionalgroup having the desired effect of reducing the rate at which thepeptide is degraded endogenously following its administration. Suchderivatized forms may be derivatized analogs of GLP-2, which carrysubstitutions, such as conserved or non-conserved lysine substitutions,having no appreciable negative effect on GLP-2 receptor activation butallowing for conjugation of the desired functional group. It will beappreciated that these derivatized forms of GLP-2 or of GLP-2 analogsare considered to be GLP-2 receptor agonists if they exert theirendogenous effect through the GLP-2 receptor after administration, evenif this GLP-2 receptor agonist property is not displayed while in thepro-drug, pre-administration form.

A wide variety of useful active GLP-2 analogs and derivatives have beendescribed in the literature, as revealed in U.S. Pat. No. 5,789,379issued Jun. 20, 2000 and related WO97/39031 published Oct. 23, 1997which teach site-specific GLP-2 analogs; in WO02/066511 published Aug.27, 2003 which teaches albumin-derivatized forms of GLP-2 and analogs,and in WO99/43361 published Oct. 14, 1999, WO04/035624 published Apr.29, 2004 and WO04/085471 published Oct. 7, 2004 which describelipophilic-derivatized forms of GLP-2 and analogs.

In a particularly preferred embodiment of the present invention, theGLP-2 receptor agonist is [Gly2]hGLP-2, known as teduglutide.

The dosing regimen effective to treat the SBS patients withcolon-in-continuity entails delivering the selected GLP-2 receptoragonist to the patient for a time and at a dose sufficient to enhanceintestinal absorption. As noted in the examples herein, and according toa preferred embodiment of the present invention, one suitable treatmentregimen entails once daily administration of teduglutide, bysubcutaneous injection in the abdomen, thigh or arm, at a dose in therange from 30 to 150 ug/kg/day for a period of about 21 days. It isanticipated that effective daily doses of teduglutide, as well as humanGLP-2 per se and other GLP-2 receptor agonist with comparableproperties, will lie generally in the broader range from about 5 to 500ug/kg/day e.g., from 10 to 400 ug/kg/day, such as 20 to 300 ug/kg/day.

It will be appreciated from these results that a similarly beneficialeffect can be expected when using either teduglutide, or when using arelated GLP-2 receptor agonist, in an alternative dosing schedule. Withrespect to teduglutide per se, administration twice daily or still morefrequently can be beneficial. Twice daily (every 12 hours) dosingusefully delivers about 5 to 250 ug/kg/dose. Benefits can also accrue toschedules that entail shorter or, more desirably, longer term dosing,such as from about 14 days to many months or even years. Maintenancedosing also is desirable, in which patients receive either continued orfollow up dosing. Follow-up dosing usefully occurs at regularfrequencies such as weekly, biweekly, every month, every three months,etc. Continued dosing usefully provides to the patient a dose efficientto maintain the benefits of increased absorptive surface area withincreased intestinal absorption that arise from initial treatment, andcan be effected by dosing the patient at least once within every 1-28days, e.g., every other day, 2-3 times per week, once per week, etc.Continued or follow-up dosing can be important to preserve the medicalbenefits mediated by the GLP-2 receptor agonist; as noted in theexamples, improvements in intestinal absorption following treatment withteduglutide for instance, can be lost rapidly, for example within fourweeks following cessation of dosing.

The teduglutide dosing regimen herein described is useful to determineeffective dosing schedules for other GLP-2 receptor agonists for whichpharmacokinetics properties are either already known or can bedetermined, by relating pharmacologic, pharmacokinetic andpharmacodynamic properties, in accordance with standard practise in drugdevelopment.

It will be appreciated that the route of administration, and theparticular dosage form of the GLP-2 receptor agonist, will be chosen topreserve and desirably optimize the effect of the drug. Administrationby injection, such as subcutaneous, intramuscular, intravenous, etc., issuitable. Alternatively, the drug may be administered by infusion or byany other route that delivers the drug to the target site on the serosalside of the intestinal tissue, such as by depot injection. If deliveredby injection, the drug can be formulated as a lyophilized powder forreconstitution by the user, and as either unit or multiple doses. Oneformulation of teduglutide, for instance, is described in WO01/49314published Jul. 12, 2001, and provides a powder for reconstitution inwhich teduglutide is present with L-histidine, mannitol and sodiumphosphate. This is usefully provided as a 3 mL glass vial containing 10mg teduglutide, for reconstitution with 1 mL water for injection andself-administration. An alternative formulation provides 10 mg ofteduglutide in a smaller volume of aqueous vehicle, such as 0.5 mL waterfor injection.

Most suitably, the chosen treatment parameters, including choice ofGLP-2 receptor agonist, and dosing schedule, are selected to provideoptimal enhancement of intestinal absorption, e.g. to provide for anincrease in the volume of fluid and the nutrients absorbed by thepatient, which is revealed for instance as a decrease of at least about5%, 10%, 15%, 20% or more in fecal wet weight, and/or an increase of atleast about 5%, 10% or more in urine weight.

Embodiments of the invention are exemplified below:

Patients

Study subjects were recruited from centers in the U.S. and Denmark thatcare for patients receiving PN. All patients had undergone extensiveresection of the small intestine without any surgical resection of thestomach, duodenum or pancreas.

Study inclusion criteria were: Over 18 years of age; diagnosis of SBSthat could be secondary to Crohn's disease, volvulus, injury or vascularischemia, remnant small intestine of 150 cm or less; no clinicalevidence of active inflammatory bowel disease (IBD) or fistulas; nohistory of radiation enteritis, or sprue; no alcohol or drug abuse; nosignificant renal, hepatic or cardiac diseases; no glutamine for atleast four weeks prior to screening; no growth factors or participationin any clinical trial within three months of screening (except use ofteduglutide in patients in the rechallenge group). SBS patients with≥50% colon-in-continuity had a demonstrated fecal weight exceeding 1kg/day and fecal energy loss exceeding 2 MJ/day [478 Kcal/day].

Women of childbearing age had to have a negative blood β-human chorionicgonadotropin test before inclusion in the study and used effectivecontraceptives during the study. Usual medications such as proton pumpinhibitors, codeine, loperamide, and oral and parenteral supplementswere kept constant. Local Ethics Committees or Institutional ReviewBoards approved the protocol. Procedures were in accordance with ethicalstandards of the Helsinki Declaration of 1964 as modified by the 48^(th)World Medical Association in 1996. Each eligible patient signed aninformed consent form prior to study.

Study Protocol

This was an open-label, pilot study to determine the safety and effectof teduglutide in patients with short bowel syndrome (SBS). Thepatient's history was reviewed and a physical examination performed todetermine eligibility before inclusion in the study. Estimated residualsmall intestine and colon lengths were determined by reviewing operativereports and available radiographic studies. Eligible patients wereadmitted as inpatients to hospital wards or General Clinic ResearchCenters (GCRC) on three separate occasions, 18 days apart, for the lastfour days and three nights of the baseline period and at the end of thetreatment and follow-up periods. Treatment consisted of recombinantteduglutide (supplied by NPS Allelix, Mississauga, ON, Canada)formulated as a lyophilized powder with L-histidine, mannitol, andmonobasic and dibasic sodium phosphate (Lot 8502901). Water was added toreconstitute the drug for administration by subcutaneous (s.c.)injections in the abdomen or thigh. Ten SBS patients with jejunostomyreceived 0.03 mg/kg/d, 0.10 mg/kg/d or 0.15 mg/kg/d once daily for 21days. Five SBS patients with >50% colon-in-continuity receivedteduglutide 0.10 mg/kg/d once daily for 21 days.

During each inpatient period, patients underwent 72-hour nutrientbalance and D-Xylose absorption studies, and a proximal or distalendoscopy to ascertain the condition of the intestinal mucosa and obtainbiopsy samples. In jejunostomy patients, biopsies were obtained throughthe jejunostomy stoma or by upper gastrointestinal endoscopy. Inpatients with colon-in-continuity, colo-rectal biopsies were obtained.Teduglutide treatment began on Day 1 (immediately after the baselineperiod) and continued once-daily for 21 days. On the first and last dayof dosing, all patients had blood collections for plasma levels andpharmacokinetic parameters and to test for any antibodies to teduglutideor E. coli protein. Patients were monitored for safety (adverse events,physical exams, vital signs, ECGs, laboratory results, and injectionsite examinations) during the inpatient periods and during outpatientvisits on days 7 and 14.

The 72-hour nutrient balance studies were completed with each patienteating their usual diet, calculated from a seven-day food diarycompleted by the patient during the screening period. It was intendedthat patients eat the same quantity and quality of food and beveragesduring each admission. During the 72-hour balance periods, all oralintake (duplicate meals and beverages and declined food), fecal/stomaloutput, and urine were collected and weighed. All stool samples wererefrigerated during the collection period. Stools and diets wereseparately homogenized and analyzed for energy content (by bombcalorimetry), nitrogen (by the macro-Kjeldahl's method), fat (by thegravimetric technique), and sodium and potassium (by atomic absorption).

D-Xylose was used to test intestinal carbohydrate absorption. After anovernight fast, patients drank a test solution of 25 g D-Xylose in200-mL distilled water over a 2-3 minute period. A blood sample wastaken at two hours and urine collected for 5-hours following ingestion.

Morphological Analysis

Endoscopic examinations were performed in each subject at the completionof baseline, treatment and follow-up phases. All tissue samples formeasurement of villus height and crypt depth were prepared and analyzedin a blinded fashion by the same pathologist. Villus height and cryptdepth were measured using light microscopy (eyepiece micrometer) as themean of ten well-oriented villi and crypts. The number of mitoticfigures per 100 crypt epithelial cells was calculated.

Statistics

Using the SAS (Version 8.2; SAS Institute, Cary, N.C.) statisticalprogram, a Student's paired t test was employed that compared treatmentto baseline values, and follow-up to baseline values. No comparisonswere made between patients on different doses or with different anatomydue to the limited number of patients in the study. Data are expressedas mean±SD. A value of p<0.05 was considered significant.

Results Patients

Sixteen SBS patients (nine females, seven males) enrolled in thisopen-label, multicenter, dose-ranging pilot study and receivedteduglutide. Four U.S. sites recruited 6 patients and one Danish siterecruited 10 patients. The baseline characteristics of these 16 patientstreated are given in Table 1. These patients were subdivided into anend-jejunostomy group of 10 (Group 2) and >50% colon-in-continuity groupof 5 (Group 3). There were originally 11 jejunostomy patients, butpatient 03 was found on biopsy to have a remnant segment of colon, laterestimated to be 30%. This individual was not included in any subgroupanalysis. As judged from analysis of duplicate meals adjusted fordeclined food, some patients had better dietary consistency than others.Patients who had an oral food intake where the dietary wet weight andenergy content at treatment did not differ more than 10% from baselinevalues were termed “high dietary compliance”. Ten patients had a highdietary compliance (<10% variability from baseline value), 5 withend-jejunostomy and 5 with ≥50% colon-in-continuity (Group 4).

The demographics of the two groups of SBS patients, those withend-jejunostomy and those with colon-in-continuity, were similar withages ranging from 27-74 years, weights ranging from 38.9-79.2 kg,heights ranging from 158-180 cm, BMI ranging from 15.0-26.9 kg/m², yearssince last intestinal resection ranging from 2.4-20 years (except onepatient 0.9 years post-resection, whose results were similar to otherswho received 0.15 mg/kg/day), and remnant jejunum lengths ranging from25-150 cm. The causes for intestinal resection were Crohn's disease(11), mesenteric infarction (2), volvulus (1), stricture (1), and trauma(1). Twelve of the 16 SBS patients used anti-diarrheal medications, and14 patients used antisecretory medications, including one [12] that tookoctreotide. Of the 15 patients who had evaluable data, 3 patients withcolon-in-continuity did not require either PN or fluids, 2 endjejunostomy patients required fluids only, and 10 patients required bothPN and fluids (Table 1).

Compliance

Jejunostomy patient 03, who was found to have a segment ofcolon-in-continuity, and patient 20, known to have colon-in-continuity,did not complete the follow-up period. Drug compliance (counting thenumber of returned vials) was complete in all patients participatingduring the nutrient balance periods. During the 21 day treatment period,drug compliance was complete, except in one patient withcolon-in-continuity, who administered the full dose for 15 days,half-doses for two days, and no dose for four days.

Safety Results

All patients were monitored for safety. There were no deaths and nowithdrawals due to adverse events (AEs). Two patients with evaluabledata reported a serious AE of catheter-related infection orcatheter-related complication following dosing. None of these werejudged to be related to teduglutide. The incidence of AEs was similarbetween groups. The most common AEs were edema of the lower limbs, andlocalized swelling of the jejunostomy nipple. Other AEs includedheadache and abdominal pain. Three patients had minor injection sitereactions (single events of bruising, induration, rash; four events oferythema). No clinically significant abnormal laboratory values wereidentified in relation to teduglutide treatment. No safety concerns wereraised from vital signs or ECGs. No antibodies to teduglutide weredetected. One patient had a relative E. coli protein antibody titer of1:1624, and six patients had relative titers between 1:107 and 1:228,after treatment.

Endogenous GLP-2 Levels

For patients with >50% colon-in-continuity, fasting concentrations ofendogenous GLP-2 were measured prior to administration of teduglutide.For four of the five subjects, their concentrations were between themean levels for fasted and fed healthy volunteers (fasted (15±2 pmol/L)and fed (61±9 pmol/L)), measured as described by Hartmann et al.(Peptides 21 2000; 73-80, incorporated herein by reference). The levelsfor the five subjects were 16, 27, 37, 41, and 73 pmol/L.

Effects of Teduglutide Wet Weight

FIG. 1 illustrates fecal wet weight, intestinal wet weight absorptionand urine weight in the individual patients in Groups 2 and 3 atbaseline, during treatment and at follow-up. A 21-day treatment withteduglutide significantly decreased fecal wet weight, compared tobaseline, in each subgroup (Groups 2 and 3; Table 2). The decrease wassimilar in those with end-jejunostomy (Group 2, 682±911 g/d, p=0.040)and those with colon-in-continuity (Group 3, 822±341 g/d, P=0.006).Absolute wet weight absorption was obtained by subtracting fecal wetweight from diet wet weight. Teduglutide increased absolute wet weightabsorption in all 15 SBS patients compared to baseline. These increaseswere significant for all groups and closely reflected the decreases infecal output. The absolute wet weight absorption increased as a percentof intake in 13 of 15 SBS patients. The increase in the relativeabsorption was similar for SBS patients with end-jejunostomy (Group 2,20±18%, p=0.007) and those with >50% colon-in-continuity (Group 3,26±16%, p=0.023). As expected from increases in intestinal wet weightabsorption, teduglutide increased urine weight in 13 of 15 SBS patients.Similar increases were seen in those patients with end jejunostomy(Group 2, 680±535 g/d, p=0.003) and those with >50% colon-in-continuity(Group 3, 461±200 g/d, p=0.007).

Energy

FIG. 2 illustrates fecal energy excretion and intestinal energyabsorption in the individual patients at baseline, during treatment andat follow-up. Compared to baseline, the 12 of 15 SBS patients hadsignificant decreases in energy excretion on teduglutide. This reductionwas more pronounced in those with colon-in-continuity (Group 3, 1343±916kJ/d, p=0.031) and those with high dietary compliance (Group 4,1060±1083 kJ/d, p=0.013) than those with end-jejunostomy (Group 2,532±1703 kJ/d, p>0.05). Significant effects were also seen with improvedenergy absorption (Group 3, 1027±798 kJ/d, p=0.045; Group 4, 963±1290kJ/d, p=0.043) and relative energy absorption (Group 3, 10±7%, p=0.030;Group 4, 8±11%, p=0.040).

Biopsies

Significant histological changes in relation to teduglutide treatmentwere seen in the jejunum in 7 of the 8 Group 2 patients who werebiopsied. There was an increase in villus height (38±45%, p=0.030),crypt depth (22±18%, p=0.010), and mitotic index (115±108%, p=0.010).These results indicate structural changes corresponded with observedimproved absorption. Small intestine biopsies were not obtained frompatients with colon-in-continuity (Group 3), however colonic biopsiesfor measurements of colonic crypt depth were obtained from thesepatients. Crypt depth increased in four of five sets of colonic biopsiesfollowing teduglutide treatment, but the mean increase of 13±22% did notreach statistical significance (p=0.330) and the increase in mitoticindex was not significant (76±112%, p=0.170). Most changes in intestinalabsorption and histology related to teduglutide treatment had reversedat follow-up.

Discussion

The main findings in this study were the considerable effects of theGLP-2 receptor agonist, teduglutide ([Gly2]hGLP-2), on reducingintestinal wet weight excretion and improving wet weight absorption inSBS patients. These effects were even seen with the SBS patients withcolon-in-continuity, most of whom had increased endogenous GLP-2concentrations. The 10 end jejunostomy SBS patients had significantlyincreased absolute (788±551 g/day, p<0.01) and relative (20±18%, p<0.01)wet weight absorption, increased urine production of 680±535 g/day(p<0.01) and decreased fecal wet weight excretion of 682±911 g/day(p<0.05). Effects of equal magnitude were seen in SBS patients with ≥50%colon-in-continuity: significantly increased absolute (751±328 g/day,p<0.001) and relative (26±16%, p<0.05) wet weight absorption, increasedurine production of 461±200 g/day (p<0.01) and decreased fecal wetweight excretion of 822±341 g/day (p<0.01). These remarkable effectswere seen in steady-state SBS patients, who were optimally treated withconventional antisecretory and anti-diarrheal medication.

The effects of teduglutide on wet weight absorption were almost two-foldthose observed in the pilot study of another GLP-2 receptor agonist,native GLP-2, for 35 days (420±480 g/day, p=0.040), conducted inpatients with similar baseline wet weight absorption. This greatereffect could be related to differences in dose and half-life of GLP-2and teduglutide, respectively. In the pilot study with native GLP-2, 400μg was given twice daily (corresponding to 0.013±0.002 mg/kg/day, arange of 0.011-0.017 mg/kg/day). The teduglutide doses in the currentstudy were 3-10 times higher, ranging from 0.03 to 0.15 mg/kg/day.Replacement of alanine by glycine in position 2 of GLP-2 blocksdegradation by DPP-IV, extending the half-life from approximately sevenminutes (GLP-2) to approximately 0.9 to 2.3 hours (teduglutide). If areaunder the curve (AUC) is critical for the wet weight absorption effect,the AUC during teduglutide treatment may well be 200 times greater thanthe AUC when using native GLP-2. In this study, effects of teduglutideon energy and macronutrient absorption were minor compared to effects onwet weight absorption. Although decreases in the fecal energy excretionof 532±1703 kJ/d, (p>0.05) and 1343±916 (p<0.05) were demonstrated inSBS patients with end-jejunostomy and colon-in-continuity, respectively,this did not translate into significant increases in absolute orrelative energy absorption. Nonetheless, the effect of teduglutide onabsolute energy absorption is 1.5 to 4-fold higher than with nativeGLP-2 (441±634 kJ/day ([105±151 kcal/day] p=0.09) at the given doses andtreatment periods. Thus, in contrast to Hz-receptor antagonists,proton-pump inhibitors and octreotide that only affect wet weightabsorption, native GLP-2 and teduglutide seem to affect both intestinalwet weight and energy absorption, with an additional positive effect onwet weight absorption in patients already treated with these non-GLP-2agonists.

Several physiological mechanisms may account for the positive effectsseen on intestinal absorption with teduglutide treatment. SBS patientswith end-jejunostomy, who have limited or no endogenous meal-stimulatedGLP-2 secretion, often suffer from gastric hypersecretion and rapidgastric emptying, at least initially after enterectomy. GLP-2 has beenshown to diminish gastric acid secretion in sham-fed healthy humans andprolong gastric emptying in SBS patients. Therefore, it is likely that apharmacological replacement may restore the physiological feedback,previously described as the ileal break mechanism. This is the firsthuman study demonstrating the intestinotrophic properties of a GLP-2analog. No other pharmacological agents have been able to promote asignificant adaptation of this magnitude, possibly as a result ofincreasing the absorptive surface area of the intestine. In the SBSpatients with end jejunostomy, teduglutide significantly increased smallintestine villus heights (38±45%, p=0.030), crypt depth (22±18%,p=0.010), and mitotic index (115±108, p=0.010).

The mechanisms regarding the effect of teduglutide in SBS patients withcolon-in-continuity are more speculative. These patients havecontinuously high endogenous GLP-2 secretion, with normal gastricsecretion and emptying. However, the supraphysiological doses ofteduglutide may produce local high concentrations that suppress gastricsecretion and induce small intestine growth. Small intestine biopsieswere not obtained in these patients. In SBS patients with and withoutcolon-in-continuity, an up-regulation of transport proteins is possibleas described in animal studies.

Regardless of the exact physiological mechanism, increases in intestinalabsorption in relation to treatments that improve intestinal adaptationwould preferably be converted into positive effects regarding bodyweight or composition, hydration, physical activity, and ultimately,quality of life. The latter two points were not examined in either studyquoted here. Body weight did not significantly increase followingtedugliitide treatment (0.9±2.1 kg, p=0.120).

The type and severity of adverse events will be an important issue whenconsidering long-term treatment in SBS patients. In this population, theserious AEs were related to the underlying condition and the AEs weremainly related to the pharmacodynamic effects of teduglutide. Theincrease in intestinal wet weight absorption may contribute toperipheral edema, which can be treated by reducing parenteral volume.

The pharmacodynamics of teduglutide appear to be intestine-specific andthe AEs are limited, therefore teduglutide may have a role in thelong-term treatment of SBS patients. The 0.75 L of improved wet weightabsorption has significant clinical implications for this SBS patientpopulation (e.g., less PN or fewer days/weeks). Spending less time onparenteral infusions may be valuable for the quality of life in thesepatients. The non-PN dependent SBS patients may also be candidates forthis treatment. Many of these patients suffer from repeated episodes ofdehydration, renal insufficiency and kidney stones. Increasing the wetweight absorption in these patients may diminish well-knowncomplications of SBS.

TABLE 1 Patient Characteristics Remnant small Base- intestine lineBaseline Dietary Dietary Dose Gender/ (cm) and Fecal Fecal ParenteralParenteral Compliance, Compliance, Patient mg/kg/ Age colon (%) WeightEnergy Fluid Energy Wet Energy Group of ID day (years) Diagnosis (cm/%)(kg/d) (kJ/d) (g/day) (kJ/day) weight (%) (%) Patients 01 0.03 F/56 CD130/0 1826 2197 2700 0 0 −9 1 2 4 02 0.03 M/56 Stricture 120/0 1348 21623500 712 74 72 1 2 03 0.03 M/32 CD UNK/30 852 1597 1300 9440 −10 73 1 040.10 M/37 CD UNK/0 4636 6275 2000 14312 −31 15 1 2 05 0.10 F/58 MI  40/04787 5988 3167 8150 5 −13 1 2 06 0.10 F/58 CD  70/0 4580 5599 3500 61803 4 1 2 4 5 07 0.10 F/74 Volvulus  70/0 2787 4451 2667 4500 −1 3 1 2 4 508 0.10 F/48 CD 150/0 1807 5972 333 0 5 9 1 2 4 5 10 0.15 F/47 CD 150/03683 10874 1000 858 −2 −2 1 2 4 5 11 0.15 M/65 CD 145/0 2237 4206 30006750 −5 −21 1 2 12 0.15 M/51 CD  90/0 4887 10273 1500 5629 −1 −18 1 2 518C 0.10 F/63 MI  50/50 2843 8537 0 0 −4 −1 1 3 4 19C 0.10 M/27 CD 70/75 2290 6240 3167 6760 2 −2 1 3 4 20C 0.10 F/39 CD 145/50 1893 51630 0 −5 −4 1 3 4 21C 0.10 F/45 CD 110/75 1807 2865 0 0 −1 1 1 3 4 22C0.10 M/36 Injury  25/50 2063 4880 2220 9540 4 −7 1 3 4 C~Patients withColon-in-Continuity (all other patients had jejunostomies) CD~Crohn'sdisease. MI~Mesenteric Infarction. Rec.~Resection of ileum, i.e., >80Rec.: More than 80 cm of small intestine has been resected. DietaryCompliance: The Difference between Oral intake of Wet-Weight in percentof Baseline intake UNK: unknown

TABLE 2 Wet Weight: Fecal Excretion, Absolute and Relative AbsorptionPatients Effect of Treatment Effect at Follow Total With Baseline Day(Treatment minus up (Follow up Patients Beneficial −3 to 0 Baseline)minus Baseline) Wet Weight Patient Groups (N) Effect Mean ± SD mean ± SDmean ± SD Fecal 2. SBS Patients with 10 8 3258 ± 1410 −682 ± 911*   278± 496 (g/day) End-Jejunostomy 3. SBS Patients with ≥50% Colon 5 5 2179 ±415  −822 ± 341**   −240 ± 426   4. SBS Patients, High Dietary 10 9 2558± 938  −769 ± 447***   93 ± 500 Compliance Absorption 2. SBS Patientswith End- 10 9  18 ± 1427 788 ± 551** −218 ± 577   (g/day) Jejunostomy3. SBS Patients with ≥50% Colon 5 5 1613 ± 1503 751 ± 328** 352 ± 525 4.SBS Patients, High Dietary 10 9 1023 ± 1369  746 ± 436***  24 ± 576Compliance Absorption (% 2. SBS Patients with End- 10 8 −7 ± 64  20 ±18** −9 ± 16  of intake) Jejunostomy 3. SBS Patients with ≥50% Colon 5 531 ± 39 26 ± 16*  17 ± 30 4. SBS Patients, High Dietary 10 9 22 ± 34 23± 16**  0 ± 27 Compliance Patients: 16 SBS Patients (II with jejunostomyand 5 with colon-in-continuity). Patient No. 03 was thought to have hada jejunostomy, but was determined to have 30% colon and was excludedfrom the analysis. Effect of treatment: paired t-test; treatment versusbaseline. *p < 0.05, **p < 0.01, ***p < 0.001. Effect at follow up:pairedt-test; follow up versus baseline, all non-significant p > 0.05.

TABLE 3 Urine Wet Weight Patients Effect of Treatment Effect at FollowTotal With Baseline Day (Treatment minus up (Follow up PatientsBeneficial −3 to 0 Baseline) minus Baseline) Patient Groups (N) EffectMean ± SD mean ± SD- mean ± SD Wet Weight 2. SBS Patients with 10 8 1257± 339 680 ± 535** 11 ± 287 (g/day) End-Jejunostomy 3. SBS Patients with≥50% 5 5 1834 ± 663 461 ± 200** −90 ± 281   Colon 4. SBS Patients, HighDietary 10 10 1509 ± 595  725 ± 394*** 30 ± 285 Compliance Patients: 16SBS Patients (II with jejunostomy and 5 with colon-in-continuity).Patient No. 03 was thought to have had a jejunostomy, but was determinedto have 30% colon and was excluded from the analysis. Effect oftreatment: paired t-test; treatment versus baseline. *p < 0.05, **p <0.01, ***p < 0.001. Effect at follow up: paired t-test; follow up versusbaseline, all non-significant p > 0.05.

TABLE 4 Energy: Fecal Excretion, Absolute and Relative AbsorptionPatients Baseline Effect of Treatment Total With Day −3 to 0 (Treatmentminus Effect at Follow up Patients Beneficial Mean ± Baseline) (Followup minus Baseline) Energy Patient Groups (N) Effect SD mean ± SD mean ±SD Fecal (kJ/day) 2. SBS Patients with 10 8 5800 ± 2919 −532 ± 1703  320± 1200 End-Jejunostomy 3. SBS Patients with ≥50% 5 4 5536 ± 2074 −1343 ±916*   −997 ± 1713   Colon 4. SBS Patients, High Dietary 10 8 5678 ±2539 −1060 ± 1083*  −98 ± 1674  Compliance Absorption 2. SBS Patientswith 10 6 5962 ± 3562  363 ± 2656 −800 ± 2958   (kJ/day) End-Jejunostomy3. SBS Patients with ≥50% 5 5 7346 ± 2483 1027 ± 798* 907 ± 1146 Colon4. SBS Patients, High Dietary 10 9 6449 ± 2099  963 ± 1290* 452 ± 1211Compliance Absorption 2. SBS Patients with 10 6 50 ± 17  5 ± 20 −6 ±12   (% of intake) End-Jejunostomy 3. SBS Patients with ≥50% 5 5 57 ± 1410 ± 7* 10 ± 17  Colon 4. SBS Patients, High Dietary 10 9 54 ± 14  8 ±11* 3 ± 16 Compliance Patients: 16 SBS Patients (11 with jejunostomy and5 with colon-in-continuity). Patient No. 03 was thought to have had ajejunostomy, but was determined to have 30% colon and was excluded fromthe analysis. Effect of treatment: paired t-test; treatment versusbaseline. *p < 0.05, **p < 0.01, ***p < 0.001. Effect at follow up:paired t-test; follow up versus baseline, all non-significant p > 0.05.

We claim:
 1. A method of treating a patient having short bowel syndromewith vascular ischemia, who receives an amount of parenteral nutritioneach week, and who presents with colon-in-continuity with remnant smallintestine, said method comprising administering h(Gly2)GLP-2 to saidpatient using a dosing regimen effective to reduce or eliminate saidweekly amount of parenteral nutrition received by said patient.
 2. Amethod as defined in claim 1, wherein the h(Gly2)GLP-2 is administeredat a daily dose of from 5 to 500 μg/kg.
 3. A method as defined in claim2, wherein the h(Gly2)GLP-2 is administered at a daily dose of from 30to 150 μg/kg.
 4. A method as defined in claim 1, wherein theh(Gly2)GLP-2 is administered by subcutaneous injection.
 5. A method asdefined in claim 4, wherein the subcutaneous injection is into theabdomen, thigh, or arm.
 6. A method as defined in claim 1, wherein thepatient is an adult.
 7. A method of treating a patient having shortbowel syndrome with vascular ischemia, who receives an amount ofparenteral nutrition each week, and who presents withcolon-in-continuity with remnant small intestine, said method comprisingadministering h(Gly2)GLP-2 to said patient using a dosing regimeneffective to increase wet weight absorption compared to a baseline wetweight absorption by said patient.
 8. A method as defined in claim 7,wherein the h(Gly2)GLP-2 is administered at a daily dose of from 5 to500 μg/kg.
 9. A method as defined in claim 8, wherein the h(Gly2)GLP-2is administered at a daily dose of from 30 to 150 μg/kg.
 10. A method asdefined in claim 7, wherein the h(Gly2)GLP-2 is administered bysubcutaneous injection.
 11. A method as defined in claim 10, wherein thesubcutaneous injection is into the abdomen, thigh, or arm.
 12. A methodas defined in claim 7, wherein the patient is an adult.
 13. A method asdefined in claim 1, wherein said regimen comprises administration ofsaid h(Gly2)GLP-2 over a period of at least 21 days.
 14. A method asdefined in claim 7, wherein said regimen comprises administration ofsaid h(Gly2)GLP-2 over a period of at least 21 days.
 15. A method asdefined in claim 1, wherein the parenteral nutrition is reduced byvolume or frequency of administration.
 16. A method as defined in claim1, wherein said patient is an adult and the h(Gly2)GLP-2 is administeredat a daily dose of from 30 to 150 μg/kg by subcutaneous injection.
 17. Amethod as defined in claim 7, wherein said patient is an adult and theh(Gly2)GLP-2 is administered at a daily dose of from 30 to 150 μg/kg bysubcutaneous injection.